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Ophthalmologic Techniques That Evaluate the Posterior Eye Segment

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Ophthalmologic Techniques That Evaluate the Posterior Eye Segment MEDICAL POLICY POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT POLICY NUMBER MP-2.056 Original Issue Date (Created): 8/9/2002 Most Recent Review Date (Revised): 7/31/2020 Effective Date: 12/1/2020 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects, multiple sclerosis, increased intracranial pressure, optic neuritis or optic nerve disorders may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography. Analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation for all other indications is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. The measurement of ocular blood flow, pulsatile ocular blood flow or blood flow velocity is considered investigational for all indications. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Cross-references: MP-2.028 Eye Care MP-2.085 Optical Coherence Tomography (OCT) of the Anterior Eye Segment MP-2.086 Retinal Telescreening for Diabetic Retinopathy II. PRODUCT VARIATIONS Top This policy is only applicable to certain programs and products administered by Capital BlueCross please see additional information below, and subject to benefit variations as discussed in Section VI below. FEP PPO- Refer to FEP Medical Policy Manual MP-9.03.06, Ophthalmologic Techniques for Evaluating Glaucoma. The FEP Medical Policy Manual can be found at: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-management- guidelines/medical-policies. Page 1 MEDICAL POLICY POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT POLICY NUMBER MP-2.056 III. DESCRIPTION/BACKGROUND Top Several techniques have been developed to measure the thickness of the optic nerve/retinal nerve fiber layer (RNFL) as a method to diagnose and monitor glaucoma. Measurement of ocular blood flow is also being evaluated as a diagnostic and management tool for glaucoma. GLAUCOMA Glaucoma is characterized by degeneration of the optic nerve (optic disc). Elevated intraocular pressure (IOP) has long been thought to be the primary etiology, but the relation between IOP and optic nerve damage varies among patients, suggesting a multifactorial origin. For example, some patients with clearly elevated IOP will show no optic nerve damage, while others with marginal or no pressure elevation will show optic nerve damage. The association between glaucoma and other vascular disorders (e.g., diabetes, hypertension) suggests vascular factors may play a role in glaucoma. Specifically, it has been hypothesized that reductions in blood flow to the optic nerve may contribute to the visual field defects associated with glaucoma. Diagnosis and Management A comprehensive ophthalmologic exam is required for the diagnosis of glaucoma, but no single test is adequate to establish diagnosis. A comprehensive ophthalmologic examination includes assessment of the optic nerve, evaluation of visual fields, and measurement of ocular pressure. The presence of characteristic changes in the optic nerve or abnormalities in visual field, together with increased IOP, is sufficient for a definitive diagnosis. However, some patients will show ophthalmologic evidence of glaucoma with normal IOPs. These cases of normal tension glaucoma (NTG) are considered to be a type of primary open-angle glaucoma (POAG). Angle- closure glaucoma is another type of glaucoma associated with an increase in IOP. The increased IOP in angle-closure glaucoma arises from a reduction in aqueous outflow from the eye due to a closed angle in the anterior chamber. Diagnosis of angle-closure glaucoma is detailed in MP- 2.085. Conventional management of patients with glaucoma principally involves drug therapy to control elevated IOPs, and serial evaluation of the optic nerve, to follow disease progression. Standard methods of evaluation include careful direct examination of the optic nerve using ophthalmoscopy or stereophotography, or evaluation of visual fields. There is interest in developing more objective, reproducible techniques both to document optic nerve damage and to detect early changes in the optic nerve and retinal nerve fiber layer (RNFL) before the development of permanent visual field deficits. Specifically, evaluating changes in RNFL thickness has been investigated as a technique to diagnose and monitor glaucoma. However, IOP reduction is not effective in decreasing disease progression in a significant number of patients, and in patients with NTG, there is never an increase in IOP. It has been proposed that vascular dysregulation is a significant cause of damage to the RNFL, and there is interest in measuring ocular blood flow as both a diagnostic and a management tool for glaucoma. Changes in blood flow to the retina and choroid may be particularly relevant for diagnosis and treatment of NTG. A variety of techniques have been developed, as described below. (Note: This policy only addresses techniques related to the evaluation of the optic nerve, RNFL, or blood flow to the retina and choroid in patients with glaucoma.) Page 2 MEDICAL POLICY POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT POLICY NUMBER MP-2.056 MULTIPLE SCLEROSIS This central nervous system disease involves an immune-mediated process, which directs an abnormal response from the body’s immune system to the central nervous system (the brain, spinal cord and optic nerves). In up to 20% of multiple sclerosis (MS) patients optic neuropathy may be the first demyelinating event. The most common type of involvement of the visual pathways is optic neuritis, which can result in varying degrees of visual loss. OPTIC NEURITIS Inflammation of the optic nerve. Often associated with MS this demyelinating and inflammatory condition occurs in 50% of MS patients and is the presenting feature in 15 to 20 percent of patients. Typically, painful, monocular vision loss evolves over hours to a few days. OCT can detect RNFL thinning in 85% of patients with this condition. PAPILLEDEMA Papilledema is optic disc swelling due to raised intracranial pressure. It occurs when raised intracranial pressure is transmitted to the optic nerve sheath. Typically bilateral, it is often discovered when individuals are evaluated for other symptoms. Visual symptoms are common, although rarely the presenting symptom. Diagnostic testing may include optical coherence tomography both to monitor swelling and to determine changes surrounding the retina. Left untreated vision loss can occur. Techniques to Evaluate the Optic Nerve and RNFL Confocal Scanning Laser Ophthalmoscopy Confocal scanning laser ophthalmoscopy (CSLO) is an image acquisition technique intended to improve the quality of the eye examination compared with standard ophthalmologic examination. A laser is scanned across the retina along with a detector system. Only a single spot on the retina is illuminated at any time, resulting in a high-contrast image of great reproducibility that can be used to estimate RNFL thickness. In addition, this technique does not require maximal mydriasis, which may be problematic in patients with glaucoma. The Heidelberg Retinal Tomograph is probably the most common example of this technology. Scanning Laser Polarimetry The RNFL is birefringent (or biorefractive), meaning that it causes a change in the state of polarization of a laser beam as it passes. A 780-nm diode laser is used to illuminate the optic nerve. The polarization state of the light emerging from the eye is then evaluated and correlated with RNFL thickness. Unlike CSLO, scanning laser polarimetry (SLP) can directly measure the thickness of the RNFL. GDx is a common SLP device. GDx contains a normative database and statistical software package that compare scan results with age-matched normal subjects of the same ethnic origin. The advantages of this system are that images can be obtained without pupil dilation and evaluation can be completed in 10 minutes. Current instruments have added enhanced and variable corneal compensation technology to account for corneal polarization. Page 3 MEDICAL POLICY POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT POLICY NUMBER MP-2.056 Optical Coherence Tomography Optical coherence tomography (OCT) uses near-infrared light to provide direct cross-sectional measurement of the RNFL. The principles employed are similar to those used in B-mode ultrasound except light, not sound, is used to produce the 2-dimensional images. The light source can be directed into the eye through a conventional slit-lamp biomicroscope and focused onto the retina through a typical 78-diopter lens. This system requires dilation of the patient’s pupil. OCT analysis software is being developed to include optic nerve head parameters with spectral domain OCT, analysis of macular parameters, and hemodynamic parameters with Doppler OCT and OCT angiography. Pulsatile Ocular Blood Flow The pulsatile variation in ocular pressure results from the flow of blood into the eye during cardiac systole. Pulsatile ocular blood flow can thus be detected by the continuous
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